Central Vestibular Disorders
Determining central versus peripheral origin of vertigo requires an assessment of the precise symptom and the presenting circumstances, as well as the physical findings. Understanding the role of migraine as a common cause of dizziness in patients presenting to an otolaryngologist provides a valuable clinical tool in managing this highly prevalent disorder that commonly manifests vestibular symptoms. The diagnosis of migraine-associated vertigo relies critically on the history and can be substantiated by monitoring the longitudinal response to diet manipulation and medical management. Effective, definitive treatment of migraine-associated vertigo requires the patient's understanding of the importance of lifestyle modification in order to promote compliance. Medical treatment includes beta blockers, tricyclic antidepressants, serotonin reuptake inhibitors, and anticonvulsants. Meniere disease and benign paroxysmal positional vertigo are commonly associated with migraine. Vascular disorders are a common cause of vertigo in the elderly population. Several types of strokes can present with vertigo, early imaging studies can be normal, and overt neurologic signs absent. Bedside tests such as head-impulse, nystagmus, test of skew (HINTS) have a high sensitivity and specificity for vascular origin disease. Neoplasms can present with vertigo; vestibular schwannoma is the most likely tumor to present with these symptoms, although tumors in the brainstem and cerebellum can also cause these symptoms. Screening for neoplasm should be considered in patients with progressive symptoms, particularly when other cranial nerve or central nervous systems exist. The otolaryngologist should be aware that multiple sclerosis, normal pressure hydrocephalus, focal seizure disorders, and cerebellar ataxia syndromes can produce vertigo.
